Reinforced LMAs for paediatric tonsillectomy增强小儿扁桃体切除昆布多糖硫酸酯.pptVIP

Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008 Day-case tonsillectomy in Epsom 98% Day-case discharge rate Benefits cost – effective Less pressure on inpatient beds Less psychological trauma for parents and children Anaesthesia 2006, 61, 116 - 122 Epsom children’s ENT day-case anaesthesia protocol Clear fluids up to 2hrs pre-op EMLA or ametop Propofol induction IV ondansetron Oxygen/air/sevoflurane rLMA in children aged 3 or older Spontaneous ventilation IV dexamethasone PR diclofenac PR paracetamol IM codeine IV crystalloids 10ml/kg Continued (Post-op) Free fluids and food on demand Nursing observations for 6hrs post-op Post-op consultant-led ward round Nurse-led discharge 6hrs post-op Theoretical advantages of LMA Avoids neuromuscular blockade Minimises pharyngeal laryngeal trauma No endobronchial/oesophageal intubation Less airway soiling Avoids extubation risks Deep Awake Airway protection until awake Evidence Canadian paeds study (1993) English adult paeds study (1993) Meta-analysis (1996) UK practice Clarke et al, BJA 99 (3): 425-8 (2007) Ninewells? Prospective survey of LMA use 3 critical stages: 1. Insertion 2. Opening of BD gag 3. recovery Methods Simple form All NW paeds anaesthetists with regular ENT lists May 2007 – January 2008 64 patients Age Weight LMA size Number of insertion attempts Quality of fit Tolerance of Boyle-Davis Gag Reposition after BD gag insertion? Reposition success? 2 successfully repositioned 3 converted to ETT Conversion to ETT Airway not acceptable with BD gag open Suboptimal fit (? Better with smaller LMA) and “chunky” child LMA obstructed completely with BD gag Overall airway quality Recovery All smooth Problems Unsatisfactory fit – 2 Airway compromised by BD gag – 3 LMA dislodged during surgery - 3 Problems (1) Age 6 43kg LMA maybe too big “chunky” child Problems (2) Age 13 65kg Lots of insertion attempts LMA never fitted well Problems (3,4,5) Ages 4-6 15-20kg Obstruction of LMA with BD gag Problems